************************************************************************ MANIFEST MARINE QUOTE REQUEST ************************************************************************ This form can be printed, filled in by hand and then mailed to Manifest Marine at 604 Stonewall Lane, Fredericksburg VA 222407, or it can be faxed to 540-785-0398. It can also be filled in on your computer and then either printed and mailed or faxed to us, or the form can be e-mailed to sales@ManifestMarine.com. In any case, we look forward to being of service. The personal information you provide will not be used by Manifest Marine or the insurers it represents except for the purpose of determining the present availability and cost of the insurance you specify below. Some insurers we represent check driving, claims and credit histories in order to determine the availability and cost of their insurance; please mention in the Comments section if you do not wish to consent to this. The contact information you provide will not be used by us or others to contact you again at a later time unless you choose to have Manifest Marine arrange such insurance for you. ------------------------------------------------------------------------ APPLICANT INFORMATION ------------------------------------------------------------------------ Name of applicant -------> Mailing address ---------> Telephone ---------------> E-mail ------------------> Occupation --------------> (if retired please also indicate prior occupation) Citizenship -------------> Driver license ----------> (number and issuer) Date of birth -----------> Years boating -----------> Years as boatowner ------> Largest prior vessel ----> (describe vessel, years owned and where operated) Second largest vessel ---> (describe vessel, years owned and where operated) Boating courses taken ---> (please also list any boating licenses held) Place an 'X' next to any of the following statements that are true: [ ] I have been cited for boating or motor vehicle violations in the past five years. [ ] I have made an insurance claim against a boat or motor vehicle insurance policy in the past ten years. [ ] I have been denied an insurance policy by an insurance company for boat or motor vehicle insurance. [ ] I have had a boating or motor vehicle license suspended or revoked. [ ] I have been convicted of a felony. [ ] Someone will operate the vessel on a regular basis without me aboard. [ ] A captain or crewman will be hired to operate or assist in the operation of the vessel. [ ] The vessel will be operated singlehandedly in cases other than an emergency. If any statement was checked, please provide details of the relevant circumstances in the Comments section at the end of this form. ------------------------------------------------------------------------ Vessel Information ------------------------------------------------------------------------ Owners --------------> (if other than applicant named above) Boat name -----------> Builder -------------> Model ---------------> Style or rig---------> Year ----------------> Length --------------> Hull material -------> Place built ---------> Place registered ----> Number of motors ----> HP each -------------> Year/make of motors -> Drive type ----------> Fuel type -----------> Maximum MPH ---------> Place an 'X' next to the types of equipment aboard the vessel: [ ] Automatic fire extinguisher [ ] Fume detector [ ] Theft alarm [ ] High water alarm [ ] RADAR [ ] VHF radio [ ] Depthsounder [ ] GPS [ ] AIS [ ] Dinghy with motor [ ] Dinghy w/o motor [ ] Liferaft [ ] Trailer Particularly if the vessel will be traveling internationally, please describe any additional safety, navigation or other equipment aboard or other preparations you have made to enhance the seaworthiness of the vessel and the safety of its crew -------------------------------------- ---------------------> Spars ---------------> none (for sailboats, specify material of the spars) Rigging age ---------> original (for sailboats, specify age of the standing rigging) Damage --------------> none (please describe any existing damage or other faults of the vessel) Survey --------------> none (date of latest professional survey and whether vessel was ashore) ------------------------------------------------------------------------ Usage Information ------------------------------------------------------------------------ Type of use -> [ ] Recreational [ ] Liveaboard [ ] Racing [ ] Trailering [ ]Waterskiing [ ] Bareboat charter [ ] Crewed charter [ ] Commercial use other than charter Time of use -> [ ] Year-round [ ] In port\\______//From ----> [ ] Ashore //¯¯¯¯¯¯\\Until ---> __//Between -> Area of use -> [ ] Coastal waters¯\\ And -> [ ] Nontidal waters of U.S. [ ] Bahamas [ ] Cuba [ ] Caribbean [ ] Mexico [ ] Canada [ ]Great Lakes [ ] Chesapeake Bay [ ] San Francisco Bay [ ] Puget Sound [ ] Other ---> Mooring -----> [ ] Regularly cruising [ ] Year-round at ------------> [ ] Seasonal___//Summer at ---> ¯¯¯¯\\Winter at ---> ------------------------------------------------------------------------ Coverage Information ------------------------------------------------------------------------ Present insurer of vessel -> n/a (new purchase) Expiration date of policy -> n/a Purchase cost of vessel ---> Date of purchase ----------> Estimated current value ---> same as purchase cost (if higher than purchase cost, describe why in Comments section) Desired insurance amount --> same as current value (if other than current value, describe why in Comments section) Deductible ----------------> [ ] 1% [ ] 2% [ ] 3% [ ] 4% (% of insurance amount) [ ] 5% [ ] 10% [ ] other -> Value of dinghy & motor ---> n/a (portion of current value attributable to dinghy & its motor) Value of trailer ----------> n/a (portion of current value attributable to boat trailer) Liability insurance -------> [ ] $300,000 [ ] $500,000 [ ] $1,000,000 [ ] other -> ------------------------------------------------------------------------ Comments ------------------------------------------------------------------------ Please use the space below to expound upon any of the information provided above or to advise us of any peculiar circumstances of which we should know. If any use other than recreational was indicated above, please provide below details of the planned use. Please also use the space below to specify any supplemental coverages in which you are interested. -> Please let us know how you came to learn about Manifest Marine. -------- -------------> *********************MANIFEST MARINE QUOTE REQUEST**********************